Explaining the treatment pathway for anorexia nervosa.
We believe that someone you care about is suffering from anorexia nervosa. They may or may not agree with this diagnosis and there are many reasons for this.
- Sometimes they believe that anorexia is not being hungry; and they are very hungry although they are good at suppressing it.
- They may be afraid of putting on weight.
- Starving makes it hard for someone to think clearly.
- They do not feel thin even if they are very thin. At the early stage of treatment it is not always helpful to insist that their thoughts are irrational
- There are aspects of this eating disorder that are useful to them. For example they secretly feel special and superior because of their ability to control their eating.
Getting someone to accept a diagnosis of anorexia is part of the treatment and this will happen slowly and at the right pace. We no longer think it is important for someone to admit that they have Anorexia because recovery depends on doing other things such as building self confidence and helping someone to fight their deep fears of food. For the time being we can help your loved one give whatever name they choose to their struggles with food.
How treatment works
First of all we know that some treatments are not very helpful for anorexia. For example there are no drugs we know that will help someone start to behave normally with food and whether to use drugs in the course of treatment will depend on psychological assessment. Force feeding is also not helpful but may be needed if there is physical emergency.
Treatment for Anorexia must be fitted to the person and will depend on many things:
- The degree of physical risk arising from food restriction, degree of weight loss and other factors such as whether someone is purging, or suffering from psychological problems such as depression. Starving will make someone depressed and anxious and for many people regaining weight will correct those features of anorexia but some people may need extra medication to help them on the way.
- Whether treatment should be in hospital, day care or outpatient is a decision also based on medical risk. The best outcomes are for outpatient treatment, although many carers just want their loved one to be in a safe place. The shortest possible hospital stays are indicated for medical emergencies and for failed outpatient treatment. Because treatment in the home is best, carers need a great deal of support, both to help their loved one and to help themselves and other family members. If this is not offered, please find a local parent’s group or find some carer counselling from an eating disorder expert.
- The first phase of treatment will involve getting to know your loved one so that they can hopefully build up trust in the therapist. This will take time because the Anorexia “fights” back when it is attacked and tells the sufferer not to trust anyone. So there is a process of getting to know the therapist.
- Ideally a dietician will design a feeding plan carefully formulated on the sufferer’s current needs and stage of maturity. If weight is very low we would not expect someone to start eating normal meals at once which could be dangerous and there may be a need to supplement a food plan with liquid meals.
- During the initial weeks the therapist will also be doing “Motivational Therapy” which helps someone to accept their problem and decide to work with therapy rather than to fight it.
- Because the nature of Anorexia is to fight against therapy, weight may continue to be lost at first and you may be very worried about this. Hospital admission is always a useful stand-by in the early stages of treatment before your loved one is able to take back some control over their illness. Even with successful treatment, many people have had several hospital admissions at first before they decide that it isn’t useful to continue living like this.
- For some people the goal of treatment must first of all be to help them stop losing weight. This might take time and they may or may not manage it on their own. Hospital treatment is a stand-by for this and don’t worry – it does not mean that your loved one will not eventually recover.
- Only after this would we be able to help them to regain weight with careful re-feeding plans tailed by a dietician. This must be supported by psychological treatment on the underlying problems that are keeping them stuck. We call these “maintaining factors” and an example of this is what we call “the Anorexic Voice” which tells them that if they start eating again they will never stop and they will become very fat. We can teach carers how to talk back to this “voice” in a way which is helpful.
- The goals of treatment are not just to help someone gain weight. We will be looking for someone to take care of themselves properly, to eat a wide range of foods in social situations and to help someone function well in their relationships with other people. This will take time, during which time the illness will still have hold of them. Anorexia is a sign that someone feels out of control of ALL areas of their life other than with food and so recovery is only possible if someone feels able to cope with life and with other people. We will be aiming to help someone reach a TURNING POINT – meaning that they and not the therapist are actively fighting against the illness.
- Many carers believe that because someone does well at school or in sports they are coping very adequately. But people with anorexia tend to be deeply perfectionist and feel inadequate no matter how well they do. Part of our work in therapy will be to help someone to notice what and how they think of food, their body image, and other things. We would aim to help them to master their thinking and behave more kindly to themselves.
- Ideally therefore, therapy would continue beyond the time that weight is regained although people may be discharged as soon as their weight gets to a certain point. Some people with anorexia may eat to get them out of treatment or hospital only for weight to fall again. This is less likely to happen if they continue to see a therapist over time.
- Carers are an important part of a treatment plan to help with resistance, food struggles and your own emotional needs. Ideally carers will be given guidance and advice on meal handling and other skills from an eating disorder professional. If you are not offered this, consider getting some help from BEAT or the NCFED; it may make all the difference to you and your family.
- Carers also often believe that therapy is “not working”; that the therapist is “not right” or complain that the therapist is not disclosing important matters to the carers and has an unhealthy relationship with their loved one. Perhaps the sufferer is “doing things” which you believe they are not admitting to the treatment team. All of these concerns must be communicated in the right way; you may be right and you may not. A common problem in anorexia treatment is “splitting” where carers and sufferers are both competing for the attention of the therapist or the treatment team. This is not usually helpful to the sufferer. Many of these problems can be managed properly if you get the support of your own counsellor or support group.
- A therapist may use different kinds of therapy to help your loved one overcome the underlying factors which make them need to starve. Cognitive therapy, treatment for trauma if there is one, dance and art therapy help your loved one express their feelings; general psychotherapy for coping skills- all can be useful. Again, these are therapies that take time to work and their effect differs from one person to another. If one therapy is not working, something else might. Sadly there is no evidence that all therapies work equally well for everyone, but keep going, remembering that 8 out of 10 people eventually recover.
Yet… 1 in 5 people will become seriously ill from their disorder and sadly succumb to it despite treatment. Think positive and remember that the statistics are on your side no matter how serious the anorexia appears to be. The illness lasts for on average 7 years with wide individual differences. And someone may be getting better before it shows up in weight gain and increased confidence.
We have another information piece that you might find helpful. You will find it also in our information pages. “Useful notes for Carers”
Written by Deanne Jade, 2010 updated 2016